| NPI | 1881735611 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: SC TL1196) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC TL1196) |
| 363AM0700X Physician Assistant Medical (Licence: SC TL1196) | |
| Enumeration Date | 2007-02-12 |
| Last Update Date | 2009-11-02 |